Journal of Thrombosis and Thrombolysis

, Volume 47, Issue 2, pp 272–279 | Cite as

Exploring the effect of factor Xa inhibitors on rotational thromboelastometry: a case series of bleeding patients

  • Syed Mahamad
  • Hina Chaudhry
  • Rosane Nisenbaum
  • Amanda McFarlan
  • Sandro Rizoli
  • Alun Ackery
  • Michelle SholzbergEmail author


Direct oral anticoagulants (DOACs) have become the standard for thromboembolic risk management. In cases of major bleeding, trauma, or urgent surgery, accurate monitoring of DOAC activity is desirable; however, there is often no rapid, readily available test. We therefore explored the degree to which DOAC activity correlated with two coagulation assays: rotational thromboelastometry (ROTEM) and a standard coagulation assay in bleeding patients. We conducted a retrospective review of patients who experienced bleeding while on DOAC therapy from 2015 to 2017 at a Level 1 trauma center. ROTEM (EXTEM-clotting time {CT} in seconds), activated partial thromboplastin time (aPTT) (in seconds), prothrombin time (PT) (in seconds), DOAC specific drug test (anti-Xa and Hemoclot in ng/mL), and relevant clinical parameters were recorded. Descriptive statistics (median, range) and Spearman correlation coefficients were estimated. Differences between correlations were tested using Williams’ t test. Twelve cases were reviewed (13 separate bleeding episodes). Sixteen measurements of DOAC activity, EXTEM-CT, and PT were obtained. The correlations with rivaroxaban activity were 0.96 and 0.86 (p = 0.2062) for PT and EXTEM-CT, respectively. The correlations with apixaban activity were 0.63 and 0.56 (p = 0.7175) for PT and EXTEM-CT, respectively. Analyses were not conducted for dabigatran due to limited data. Although not statistically significant, PT appears to have a higher correlation with direct Xa inhibitor activity than EXTEM-CT. Further research with larger samples is necessary to clarify the differences between ROTEM and standard assays in detecting DOAC activity.


Direct oral anticoagulant (DOAC) Thromboelastometry Factor Xa inhibitors Rivaroxaban Apixaban Trauma 



The authors would like to acknowledge the support from our research manager, Ms. Jessica Petrucci.

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.

Supplementary material

11239_2018_1785_MOESM1_ESM.docx (30 kb)
Supplementary material 1 (DOCX 31 KB)


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Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2018

Authors and Affiliations

  • Syed Mahamad
    • 1
  • Hina Chaudhry
    • 2
  • Rosane Nisenbaum
    • 3
    • 4
  • Amanda McFarlan
    • 6
  • Sandro Rizoli
    • 5
    • 7
    • 8
  • Alun Ackery
    • 9
  • Michelle Sholzberg
    • 1
    • 2
    • 3
    • 10
    • 11
    Email author
  1. 1.Division of Hematology/OncologySt. Michael’s HospitalTorontoCanada
  2. 2.Department of Laboratory Medicine & PathobiologySt. Michael’s HospitalTorontoCanada
  3. 3.Applied Health Research Centre, Centre for Urban Health Solutions, Li Ka Shing Knowledge InstituteSt. Michael’s HospitalTorontoCanada
  4. 4.Division of Biostatistics, Dalla Lana School of Public HealthUniversity of TorontoTorontoCanada
  5. 5.Surgery & Critical Care MedicineUniversity of TorontoTorontoCanada
  6. 6.Trauma Program and Quality AssuranceSt. Michael’s HospitalTorontoCanada
  7. 7.Trauma & Acute Care ServiceSt. Michael’s HospitalTorontoCanada
  8. 8.Trauma CareTorontoCanada
  9. 9.Department of Emergency MedicineSt. Michael’s HospitalTorontoCanada
  10. 10.Department of MedicineSt. Michael’s HospitalTorontoCanada
  11. 11.St. Michael’s HospitalTorontoCanada

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